DLD & Education

Today there has been a web chat run by @DLDandMe all about the impact having a language disorder has on a child’s education. It is part of their wider work to raise awareness of Developmental Language Disorder  (DLD) and to spread the word to a broader audience, about what DLD is, how to recognise it etc. I joined in a little, although late, but I thought it might be useful to share more detail about this topic, from our own personal experience.

As most readers already know, I am both a speech and language therapist and Mum to our seven year old son – LB – who has DLD. There is a complication to our story, which is that LB experienced early neglect and didn’t come into our lives until he was three and half. It is pretty impossible to pick apart the different impacts of neglect and DLD, with both having made their mark. However, it was clear from fairly early on that the communication difficulties LB experienced were more significant than delay alone and where progress was quite quick in some areas, speech and language has always proved more challenging for him. As much as possible in this post, I’m going to focus on the specific ways DLD has affected LB’s educational progress, notwithstanding the separate effects trauma has had.

LB’s DLD impacted on all areas of his communication development when we first met him – including his ability to understand language (comprehension), his auditory memory, his ability to use words and make sentences (expressive language), his ability to listen and pay attention, his ability to speak clearly and his social communication. When I talk about his presentation back then, in workshops and the like, I can see that it shocks people. And it was shocking, because LB’s language system just couldn’t do what he needed it to – not one part of the complicated whole functioned as it should have. He was very much trapped inside of himself and he wasn’t left with many options other than to express himself through his behaviour.

In the early stages of his pre-school education, this impacted him in a myriad different ways. He was certainly delayed in learning concept words such as his colours, size words, same/different etc. which meant he just couldn’t follow much of the teaching or express answers to what nursery staff would likely consider easy or every day questions. That said, with specific teaching of one concept at a time and plenty of reinforcement in everyday activities and play, LB was able to close the gap pretty quickly. It isn’t that LB can’t learn, because he has developed phenomenally quickly, it’s just that he couldn’t pick these concepts up from the ether, as children with typical language skills would. He required specific teaching, repetition and showing, to get them to stick.

Obviously, struggling with comprehension made it even harder for LB to learn new things. There must have been much of what went on in Nursery that he couldn’t follow. This no doubt exacerbated his difficulties with listening and attention, because it is extremely hard work for anybody to focus on language they don’t comprehend. Imagine having to listen to French or Urdu or Finnish or any other language you aren’t familiar with, for large swathes of each day. It would be exhausting and it wouldn’t take long until you stopped listening. Therefore, in some ways, LB’s DLD exacerbated his DLD. He certainly coped better on a 1:1 and thankfully we were able to provide him with this because I was on adoption leave and he just went to pre-school for a few sessions (and now he has TA support). Keeping distraction levels down and matching our language to the level LB could cope with, was imperative. It meant we could keep language accessible for him most of the time and choose which concepts or structures we wanted to stretch him with. I guess this is where my professional background came in – I suspect creating these ideal learning conditions would be much more difficult for a child whose parents are new to the idea of DLD and whose pre-school setting don’t get it.

Certainly as LB’s comprehension developed, so too did his ability to learn. I know it sounds a bit ridiculous but he did appear to be growing cleverer. I maintain that had he have had a cognitive assessment at the beginning, and one a couple of years later, he would have climbed the percentiles. This is because learning and education is generally acquired through the currency of language. As he acquired more words, he knew what more things were. He was able to express how things work. He was able to enquire and find more information out. The more language you have, the better you become at gaining it. Initially, we just couldn’t have talked about complex ideas such as electricity or natural disasters or endangered animals or health conditions. LB didn’t have the vocabulary to access a discussion or explanation about such things so he essentially wasn’t able to learn about them. It was only when he had gained sufficient depth and breadth of vocabulary and could listen to and follow longer structures, that he was able to develop his knowledge of the world around him. And when this did happen, it was amazing to witness the world opening up to him.

Vocabulary acquisition was a huge ongoing challenge for LB (and me) for a long time. Initially, even though we used lots and lots of modelling strategies, he didn’t seem to be growing a larger vocabulary. Again, like with other aspects of his language system, the more he heard a word used and the more times he managed to store a new one, the better his language processing system got. He has certainly got quicker at acquiring new words, even if this continues to be hard for him. Evidently LB’s language processing system (the bit of our brains that hears words, de-codes them, decides what sounds are in them, and their meaning, and stores them in an organised way, ready to be spoken) was not well-developed. It was laborious for him to use it, meaning that getting his vocabulary as big as he needed it to be must have been an exhausting task for him.

Where LB would once have needed to hear a word used around him for several months, with a high level of repetition, before being able to store and use it, he can now store a new word almost immediately. This has had a huge impact on his ability to be able to keep up with the curriculum. Each new topic brings a cornucopia of new words, which children are expected to immediately absorb in order to follow teaching. If you can’t understand the new words, it’s extremely difficult to follow the new lessons.

Although speedier, LB’s processing system remains inaccurate – he struggles to de-code words so that, without help, he might store ‘Corvette’ as “courgette” or ‘submarine’ as “subramine”. He is aware of this so often requests help – just having someone break a word down into bite-size syllables is a huge help to him and allows him to store a new word correctly. At school he has word webs for new words and is building up a personalised dictionary with his TA.

Despite all the hurdles, LB’s comprehension skills have caught up. He seems able to access the vast majority of teaching in his year 2 classroom without too much difficulty. He does cope better with multi-sensory teaching and visual supports (such as narrative grids, Mind Maps etc.), not least because they help to hold his attention. When LB is tired, his skills in this area do diminish a little and he might need a bit more repetition but overall I think his progress underlines what the right speech and language therapy input can achieve for children with DLD.

LB’s difficulties with auditory memory have impacted in several ways – most notably on his ability to blend sounds together and to learn listed information. Literacy acquisition was always going to be a challenge for LB, as his speech continued to be unintelligible well into year 1, with vowel distortions, and his sound awareness skills (identifying the first sound in words, rhyme, syllables etc) were poor. Even the pre-reading task of describing what’s happening in a picture was ridiculously difficult, because LB didn’t have the sentence structures or vocabulary he needed in his expressive language – something else we taught specifically.

We worked hard on sound awareness in a stepwise manner – identifying the first sound of short words then longer words, then the last sound of short words etc., alongside attending speech and language therapy. Again, I feel that good phonological awareness skills are something LB wouldn’t have been able to acquire organically, but he was very much capable of achieving on a 1:1 basis with a personalised approach.

We stumbled at the point of blending sounds together – a critical final step before literacy could be gained. The difficulty it turned out, after a bit of ‘diagnostic therapy’ (again, thank goodness for my career) was the blasted auditory memory which was struggling to hold three sounds, let alone stick them together. Once more, practise paid off and eventually LB could blend. Which, having already learned his letter shapes – pretty easily, it was a visual task – meant he could read. Progress has been steady since that point, with him progressing through the reading levels as you’d expect. In my opinion, a good phonics approach is essential for a child with DLD. It was a challenge to establish that strong foundation but once it was in place, it served LB well. He is not yet meeting the expectations of the curriculum but his reading is good; he understands text and he can apply his phonic skills to decipher most words. Crucially, he loves books and listening to stories. Keeping things as fun and engaging as possible is another essential tool in encouraging a child with DLD.

However, LB is not yet ready to apply his phonic skills to writing, finding this laborious. The addition of SPAG requirements such as including a noun phrase, or adverbial, pretty much renders writing the very worst aspect of school life for LB and, in my humble opinion, totally takes the fun and imagination out of it for all children.

It is hard to get LB’s teachers to understand just how many demands writing places on the language system of child with DLD. My hunch is that when his reading skills are better still and he’s had more specific phonics teaching, his ability to spell will improve. I suspect that expressing himself on paper, with appropriate grammar, will always have its challenges.

The other area auditory memory difficulties have impacted is LB’s ability to learn listed or sequential information such as the days of the weeks, months and, perhaps most crucially, how to count. Learning the numbers to ten proved extraordinarily challenging for LB so that when he started school, aged 4 and half, he couldn’t count to three in the correct order. The knock on effect of this was that Maths was pretty much impossible. How can you do sums when you haven’t the basic language for it? When “4” or “732” are just as meaningless and unquantifiable? This certainly held LB back and for the first year, perhaps two, of his education, his literacy skills appeared better than his numeracy ones, which lagged significantly behind. However, all the repetition and visual representation eventually paid off and LB learned to count to 10. And then 20. Very soon after that, probably because he could use his logic and ability to see patterns, he could get to 100. Once he had the language, Maths wasn’t so hard at all. In fact, it looks as though LB will meet the expected levels of the National Curriculum for the first time this year, which is no mean feat, given his starting point. Now that he has the language, even the reasoning SATS paper is accessible to him, despite the problems being presented in word form.

Having DLD has made every aspect of LB’s education more challenging for him. However, with the right support, LB has proved over and over again, what children with DLD can achieve and how crucial getting that support in place is. Language underlies all learning and we ignore that at the peril of children with DLD.

 

 

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DLD Awareness Day 2018

It’s been a hefty week for blog-fodder with both National Adoption Week 2018  and International Developmental Language Disorder Awareness Day (Friday 19^th October) landing at the same time – two events I am always keen to talk about.

This year’s theme for DLD day is the ‘ABCs of DLD’. The ‘A’ represents assessing our understanding of DLD. If you want to test how much you know, you can take this handy  Quiz

When I reflect on what I know about it, my professional experience as a speech and language therapist has mainly been usurped by my experiences at home, parenting my son who has DLD. He is currently 6 years old and in Year 2 at school. He has been discharged from speech and language therapy because his scores for both comprehension and expression of language now measure within the expected range for his age. A key thing I have learned is that with the correct intervention, children with DLD can make incredible progress and can catch up (see Speech Therapy Works  for more detail).

Although Little Bear has made unbelievable progress, he does still have DLD. He largely copes well day to day but there are specific times when I notice a difference in how his language system works compared to other people. One time is when he tries to learn a new word or a new name. Little Bear requires much more repetition of unfamiliar vocabulary and often needs me to break new words down into syllables so he can learn them in manageable chunks. He is very good at learning and retaining new words now but the processing part of his speech system isn’t as smooth as it should be and he would struggle to store new words without some specific teaching. If he doesn’t have help to ensure he understands what a word means and what all the bits of it are, he might struggle to say that word correctly e.g. ‘Emily’ recently came out as “Elle-uh-me” and ‘Joseph’ as “Jo-Fitz” or he might mis-store the word e.g. when Little Bear puts on a tall pointy hat, he says he’s being a ‘lizard’ (he means wizard) or he tells me to find things on the ‘window sledge’. Little Bear also uses ‘about’ instead of ‘without’ so will say, “It’s hard to sit on this chair about falling off it.”

Little Bear has good awareness and he knows he’s making the sound errors (he isn’t always aware of the naming errors). He often looks to me at these points to do a bit of speech therapy on the fly to help him. Children with DLD are not un-intelligent. They can learn and retain information like other children, as long as the information is presented to them in an accessible way and/or suitable strategies are employed to help them.

Little Bear’s DLD is also noticeable when he is tired or when he is faced with too much auditory information. He still copes better if large chunks of information are broken down for him and in a conversation it helps him if you are willing to repeat some parts of what you’ve said. He does generally understand the concepts you are talking about and any explanations you give to help him but he can need a little longer to process them, more pauses and sometimes a second chance to listen to the information. If words sound very similar, Little Bear can struggle to differentiate between them e.g. fourteen vs forty, which can impact on his understanding of what he’s heard.

Most of the time, Little Bear can express his thoughts and ideas competently with language, even if they are complex. Occasionally he forgets to reference what he is talking about and we have to ask a few questions to catch up with him. There are some parts of grammar that he makes occasional errors with. We still use modelling strategies at these points.

I think it can be difficult for people who don’t know him well or teachers to see his DLD straight away. Now that his speech sounds are much more accurate, his language difficulties appear more subtle. It isn’t a surprise that DLD is a hidden condition and is widely underdiagnosed or misdiagnosed (see Ensuring Children’s Speech and Language Needs Are Met: A Call to Action for more info).

This brings me to the ‘B’ of the ABCs of DLD – build knowledge.

If you’d like to read more about what Developmental Language Disorder (DLD) is, you can read this previous post: Developmental Language Disorder

DLD is much more prevalent than most people think – 7 times more common than Autism. If you want to estimate how many children are likely to meet the criteria for DLD in your school, you can use this calculator tool: Calculator Tool

A particularly useful source of information to expand your knowledge of DLD is the new RADLD website: www.radld.org

As DLD is often hidden or missed and the consequences of lack of diagnosis/misdiagnosis are so concerning (increased likelihood of unemployment, mental health difficulties and involvement with the criminal justice system) it is imperative that we work together to raise awareness, hence ‘C’ is for create awareness and is my main focus for the day.

Here are some of the things I will be doing to create awareness:

• Emailing my children’s school to share information about DLD and the RADLD website
• Sharing information on my social media channels including tweeting with the hashtag #DLDABC throughout the big day and sharing #my3forDLD
• Sharing this blog
• Wearing my newly printed RADLD campaign t-shirt and hopefully explaining what it’s all about to people who ask me
• Our local newspaper has agreed to print an article I’ve written about DLD on the 18^th. It is going to include a photo of me wearing my campaign t-shirt (their idea, I’m a bit scared and frankly too many people have seen my face this week already!).

 

If you’d like to join in with the fun and make a difference at the same time, you can:

• Use the hashtags #DLDABC and #my3forDLD on Twitter, sharing knowledge, thoughts or ideas
• Share this blog far and wide
• Tell one person what DLD is
• Contact your children’s school to let them know about DLD Awareness Day and the RADLD website (feel free to send them this post)

 

If you have any concerns about your child’s language development or a young person you are working with, contact your local speech and language therapy service. Getting the right support has made an enormous difference to Little Bear. I asked him what difference it had made: “A lot. A big difference because I wasn’t good at talking. It was tricky. My talking is lots better than before. Miles better! I’m good at writing now.” He went on to say that speech therapy was fun and he missed ‘the lady’.

It is never too late to put support in place. Ideally, identification of DLD would be early and support would be tailored and intensive but if the signs have been missed, it isn’t too late. Support in the teenage years continues to be effective.

Teachers, health visitors, social workers, the police, lawyers, people who work in public services (amongst others) all need to know about DLD. They need to know it exists so they can be better at spotting the signs. When we see disruptive behaviour, particularly in classrooms, we need to consider DLD. If we want to improve outcomes for children like Little Bear, we need to spread the word; we need people talking about DLD. Let’s see if we can make that happen…

Speech Therapy Works

As a Speech and Language Therapist it shouldn’t really be a revelation to me that speech and language therapy works. Obviously I have always believed in it otherwise I wouldn’t have stayed with it as a career for over 14 years. It’s just that trusting something works because you understand the theory behind it and actually experiencing something on a practical level, within your own home, with your child, is quite different.

Obviously I have experienced success in my professional life, but that has been within the confines of a large caseload and various time and resource pressures. In the latter part of my NHS career, as a more senior clinician, my main role was assessment and report-writing. I rarely did any therapy as we had a structure where skilled assistants carried out care plans under our supervision. It meant I didn’t get to know children as well as I’d have liked and I didn’t get to share in their small steps of progress week by week. I re-assessed and reviewed progress, seeing improved assessment scores but that isn’t the same as cultivating progression yourself.

Now that I’m an independent therapist I’m really enjoying being able to properly get to know the children I work with. I’m completely invested in their therapy and am just as pleased when they move forwards or overcome something as I am when Little Bear does. I do see (and feel) therapy working now.

However, what we have experienced at home has taken my belief in speech and language therapy to a whole other level.

I was recently running a communication workshop (for adopters, prospective adopters & professionals) when somebody asked me a question that made me realise the examples I talk about in it, from Little Bear’s communication profile, paint a bleak picture. The picture is totally accurate and reflective of his communication skills when we first met him, aged 3 and a half. The picture, detailing significant difficulties with attention and listening, comprehension, expressive language and speech sound disorder was bleak. At the time I was fairly overwhelmed by his level of need and the magnitude of the task ahead of us.

Here is a very brief summary of Little Bear’s presentation then:

Little Bear was not tuned into language at all and did not respond to verbal instruction, including his own name. His comprehension was better than it appeared but significantly delayed for his age. Little Bear had a very small vocabulary that didn’t meet his needs. He did not have words for common, everyday objects such as cow, train, television, food items etc. Little Bear couldn’t answer ‘what’s your name’, his only size word was ‘big’, he couldn’t name colours or count and he couldn’t put more than about 3 or 4 words together. The words that Little Bear did have were unintelligible. Little Bear was extremely frustrated and he was often left with no other option but to express himself with his behaviour.

I quickly realised this wasn’t a straightforward language delay and that Little Bear’s needs met the criteria for Developmental Language Disorder

At the time I had no idea what the prognosis would be but I suspected it wasn’t rosy and that speech and language therapy would be a big part of our lives for years to come. It was hard to know where to start and easy to become overwhelmed by priorities. There were times I really questioned my faith in what I was doing and wondered if we’d ever get to where we were hoping to go.

I did not expect, in my wildest dreams, that 2 and a half years later a speech and language therapist would observe Little Bear in his mainstream classroom and say there was no discernible difference in language skills between himself and his peers and deem him ready for discharge. Yes, his attention and listening skills still mark him out and there are some minor speech errors but his comprehension and expressive language skills are now within the expected range for his age.

This near miraculous improvement is due wholly to one thing: speech and language therapy.

Admittedly our circumstances are unusual: most children with DLD do not have a parent who is a speech and language therapist and able to provide targeted intervention on tap 24/7. Little Bear has essentially undergone an intensive 2 and a half year block of therapy. Strategies have been used by the whole family and are an automatic part of the way we talk with Little Bear, not something we use for just a couple of minutes each day. The key strategies have included: using environmental sounds to capture Little Bear’s interest as a way in to listening to language; reducing our language; modelling of vocabulary, sentence structures and sound patterns; repetition; showing, explaining & checking understanding of complex concepts or new words as well as seizing every possible communication opportunity. We have done some direct work on auditory memory, phonological awareness (initial sounds, syllables, rhyme, blending sounds together) and speech sounds.

I suppose at any one time I have always had a current communication aim in mind, whether it has been a specific language concept or speech sound and I have found ways to weave this into play or our usual day to day lives. I have very rarely, if at all, asked Little Bear to sit at a table and ‘do speech therapy’, it has been a much more holistic and inbuilt approach than that.

Little Bear has also been seen by an NHS speech and language therapist throughout the past 10 months or so. She has taken the lead on sorting out Little Bear’s disordered vowels which have been complex to assess and set goals for. Generally she has started us off with a sound or activity and we have carried it on between sessions.

The NHS therapist has also set language goals for school and has provided them with programmes to carry out, which they have done.

All of these strategies, techniques and approaches have worked. Their effectiveness is inarguable. Yes, the sum total of the input Little Bear has had is massive and yes, me being a speech and language therapist does make things different. However, I truly believe that a similar impact could be gained by providing parents with good quality, strategy based communication training alongside regular sessions with a speech and language therapist, who could do the assessing and target setting bits, as well as providing resources and guidance. Similarly, if speech and language techniques can be embedded into teaching and used holistically as part of the curriculum (not here and there for 10 minutes) that too can be highly effective and impactful.

Little Bear is living and breathing proof of the efficacy of speech and language intervention. Prior to treatment when I’m almost certain that no strategies were in place, he made negligible progress. In fact, on entering pre-school shortly after coming home, Little Bear was assessed as having a delay of more than 2 years in all areas of his development, with speech and language and numeracy being the most delayed areas. Within 2.5 years of therapy, that gap has closed (meaning that Little Bear has essentially made 4.5 years’ worth of progress) and his comprehension and expression now measure within age expectations on standardised assessment.

Speech and Language Therapy works.

Whilst his progress has been phenomenal, I should point out that speech therapy is not a panacea. Little Bear still has DLD and I suspect it will impact him to a greater or lesser degree into adulthood but what therapy has done for him is allowed him to reach his communication potential, despite having DLD. Little Bear still finds it difficult to learn new vocabulary and to figure out the sound patterns in new words but we know what to do and the strategies work. The approaches that we have built into our daily lives will continue as Little Bear is still going to need them and it is imperative we continue to strive for that meeting of full potential. As the demands of the curriculum increase, we might find we need to access formal therapy again and that would be okay too.

I feel extremely proud of Little Bear’s progress and find myself constantly marvelling at the things he can say now. Last week he took part in his second school assembly. He learned more than double the words he managed last time and was able to recite them in front of the school without any prompts at all. The naughty streak in me did notice that other children in his class had to read their lines or forgot them completely (I don’t mean that badly, it’s just he has never been able to keep up with them before, let alone outshine anyone and he’s more than earned his moment of glory). Not only that but he sat really well throughout, no teacher attached to his side like previously, and he spoke loudly and clearly. Several people came to me afterwards to comment on how well he had done, the difference being so stark in comparison to previous public appearances.

I am truly grateful to speech and language therapy for not only giving me a career I love but for unlocking my son.

 

 

I think I had better make some changes to my workshop too. Although people need to see the bleak picture, they also need to see the sunshine over the rainbow picture that can be gained by using the strategies and applying them diligently. Little Bear’s prognosis appeared extremely poor so his progress really is a beacon of hope.

 

 

Communication Difficulties: Update

Over the lifetime of my blog I have talked about Little Bear’s communication difficulties quite a bit: first of all in Living with Speech and Language Difficulties then later in A bit of a rant, Another try at SaLT and SaLT, EP & an Assembly. In the most recent posts I have focussed on our quest for formal speech and language therapy rather than Little Bear’s communication needs per se. As therapy has been going pretty well, I thought it was time for a look back at the development of Little Bear’s communication and how priorities have changed over time.

When Little Bear first arrived his primary communication need was to develop his listening and attention skills. Little Bear simply wasn’t tuned in to language – he ignored it in pretty much the same way you would ignore background noise. He didn’t see the point of it and sadly I don’t really think he thought it bore any relevance to him. Little Bear’s listening skills were poor which impacted on his ability to understand language and on our ability to get him to co-operate.

I can remember wandering around a beach with him during Introductions. In my typical SaLT fashion I talked to him as we wandered. I pointed things out and named what we saw. Little Bear found this completely alien and tried to shrug me off like a nuisance insect. I think he even took to shushing me. Equally he did not respond to his name or any other command. Getting him to behave and keeping him safe was incredibly difficult without the use of language.

Over time we worked on this, mainly by keeping listening fun to start with – lots of drawing his attention to passing noisy things such as aeroplanes or dogs or sirens. I definitely found that in order to engage Little Bear with listening, we had to start with non-language tasks. We were probably quite silly and playful too, which helped.

As Little Bear’s listening skills improved a bit, we were able to work on his comprehension at the same time. Probably as a result of the listening and attention issues, Little Bear’s understanding of language was certainly delayed for his age. We noticed that he often said “what?” and needed us to repeat things for him, sometimes several times. We all reduced our language from the beginning to help him understand as there was a clear pattern that the more complex the vocabulary or the longer the instruction/ explanation the more Little Bear struggled.

Little Bear’s vocabulary was very poor for a 3 and a half year old so we did lots and lots of modelling which has developed both his understanding and his expressive language. I think if I had to pick one strategy that has been the most effective I would say modelling. There are several reasons. Firstly you don’t need any equipment to model language – you can do it anywhere and completely spontaneously which makes it very practical within busy family life. You can easily work to your child’s level – either just modelling back their sentence without errors or by adding in an extra word to extend their sentence length. I would often have a couple of targets in mind at any one time e.g. for Little Bear to understand the concepts of same/different, so would model those concepts each time an opportunity arose in play or just when out and about.

You can use modelling to develop any aspect of communication – initially I used it mostly for vocabulary and sentence building. I have moved on to using it for grammar and speech sound accuracy. I don’t think I would have predicted that it would be as effective as it has been: Little Bear’s progress has been huge. The great thing is that it is a very positive approach and at no point has it felt like I’ve been nagging or correcting Little Bear. In fact he got so used to me using the strategy that if I didn’t model back his sentence after him he thought I wasn’t listening properly and would repeat himself until I did! This is in stark contrast to the boy who didn’t want me to talk to him at the beach.

Little Bear’s comprehension is now patchy on formal assessment. His understanding of basic concepts such as hot/cold, first/last, same/different is within the expected range. His understanding of different sentence types is at the low end of average and his understanding of complex sentences continues to be below expectations. However, in everyday life we have noticed leaps of progress.

I recall one day driving past some electrical cables that had come down in a storm. My natural instinct was to point them out and tell Little Bear about them but I remember stopping myself because I knew that he had no idea what electricity was and I wouldn’t be able to find a way to explain it that he would be able to follow. These days his wider understanding of life is growing all the time. I recently mentioned London in passing and he said “they had a nasty fire there, people died” and another time we were looking at a map and I said “that country is America” and Little Bear piped up “is that where Dobald (Donald) Trump is building his wall?”. He is full of surprises these days and it’s brilliant to see his understanding of complex concepts developing all the time.

Little Bear’s ability to express himself on arrival was also poor. I remember him saying “you came back” on the second day of Intros and this being quite a momentous sentence. On the third day he said “you came back again” which was poignant and sad and lots of things but also the longest sentence I heard him say for a while afterwards.

I don’t think it is any coincidence that Little Bear’s behaviour was as it was. His lack of ability to ask questions, negotiate, explain himself and talk himself out of situations certainly lead to a high level of frustration and anger and the unavoidable need for some very expressive behaviour.

For a long time Little Bear expressed himself through pointing and enthusiastic use of “that”. He had some stock sentences that all followed the same structure: I go running, I go playing, I go sleeping. He used the words he did have creatively to get his points across e.g.“bik” (big) meant lots, tall, deep, full, massive.

Little Bear’s expressive language now comes out as being within the expected range on the Renfrew Action Picture Test. I don’t honestly think this is an entirely accurate representation of his abilities but he does use lengthy compound sentences and I have noticed that being able to do so has helped him in many ways. Just today he had his IPad in the car and I heard a crash as though he had thrown it on the floor. “Did you throw that?” I asked him, “No Mum, I tried to put it on the seat but you went too fast and it slipped on the floor”. I have no idea if this was true but I had to credit him with the good explanation. Previously I might have wrongly assumed he had chucked it and he might have got into trouble and not been able to defend himself. Having improved language skills has definitely helped with behaviour in more ways than one.

A big indicator of Little Bear’s progress with his speech and language skills is that now he is having formal SaLT our agreed priority is his speech sound system. It is generally agreed that language should be the main priority with speech being more of a secondary skill. Our decision to focus on his speech is due to his language skills being good enough and his speech now being the biggest barrier to his communication. It is funny how priorities have changed.

Little Bear’s speech was pretty much unintelligible at the start. Then we tuned in and as he didn’t have many words it didn’t take long for us to be able to translate. That was all well and good until his vocabulary sky rocketed and then we were back to having no idea what he was trying to say again.

Using mainly the modelling strategy we have targeted voiced/ voiceless confusion (“beas” for ‘peas’), articulation of ‘l’ (there was a little more than modelling involved in that one but not much), production of l clusters (pl, cl, sl, fl etc) and some random inconsistent/ storage errors e.g. “gog” for ‘dog’, “nogat” for ‘yoghurt’, “mu-ey” for ‘money’, “di” for ‘dummy’ etc. However, despite all that, at the start of SALT, Little Bear was still fairly unintelligible to the therapist at the age of 4 and a half. It transpired that his vowels were jumbled which was resulting in very unusual sounding speech – his teacher had even asked me if he was foreign.

At this point, although I am a SALT and had worked on lots of aspects of Little Bear’s communication myself, I was glad and relieved to have another therapist on board. Vowels are complex, they are in all words and I couldn’t really see the wood for the trees. I was pleased to have somebody to defer to for clinical decision making. She didn’t really know where to start either so after identifying which vowels were going wrong, we pretty much just plumped for one to have a go at. It was ‘eye’ as in pie, pipe, kite, nine, five etc (for non-SaLTs think about how they sound, not how they are spelled). It turned out that Little Bear could make this sound and he could say it correctly after a consonant e.g. pie but as soon as a consonant was added after it (pipe) the vowel distorted. In this example it became “pap”. Little Bear could hear the difference between pipe and pap which helped.

Once we had figured this out and done one session of therapy, Little Bear had cracked it and was spontaneously generalising the sound. We were both unprepared for it to be that quick. I was also surprised by how often that vowel crops up in English and therefore what a difference working on it made to his intelligibility.

We have since worked on ‘ow’ as in house, mouse, brown which were coming out as has, mas, bran. Little Bear acquired ‘ow’ in much the same way as ‘eye’. We then tried ‘err’ for no particular reason other than because it was another he couldn’t say but for some reason that one just isn’t coming so we have switched to ‘ay’ as in pay, plate, eight. Little Bear can say it in words but is not generalising it as yet. I am now getting a bit tangled up with which vowels I need to model for him!

The formal therapy is pretty good though it is not completely plain-sailing.

I had thought it would be helpful for me to keep in touch with the therapist via e-mail between appointments so I could keep her updated and take away the need for her to change her session plan on our arrival – this happens most weeks due to Little Bear’s unexpected/erratic rate of progress. However, apparently this would be against policy which seems odd to me. I frequently used to use e-mail to keep in touch with parents and think this is a missed opportunity.

Also, it turns out that Little Bear is now entitled to therapy in school because he has top-up funding. However as his speech requires specialist input from a therapist only, he has been deemed more appropriate for clinic therapy. I suggested that maybe the funding could be used to train school staff to work on his language targets alongside this. Apparently it cannot be done because the school team and the clinic team are separate and you cannot be on two lists at the same time. Whilst I get this, I can’t help feeling frustrated at the lack of flexibility and feeling a little like he’s missing out on his entitlement. A system with two rigid lists does not have children and their individual needs at the centre of it.

Either way, Little Bear continues to make fabulous progress and for that I am extremely thankful.

Schools Out

For the past fortnight the Bears’ school has been in transition, with each class getting settled in their new classroom and with their new teacher. Things seem to have gone fairly smoothly but I checked in with Little Bear’s teacher yesterday, just to be sure.

I wrote a few weeks ago in Support about school (and us) having secured funding top-up funding for Little Bear. I have recently found out that the school have been able to advertise for a TA and that they have employed somebody and this person will provide Little Bear with 20 hours of support per week. Obviously this is great. They will work from 8:30 am so will be able to greet him and will finish at 12:30 meaning he gets support for some of his lunch time – a flashpoint when things often go awry. He will have 1:1 or small group support available for all his core subjects.

I’m very pleased about this.

Things are never perfect though and there are a couple of little niggles at the back of my mind. Firstly I didn’t expect the TA to be anybody that I knew. It turns out she is a parent of children in the same school. I don’t know her but I know of her as she has previously volunteered in the school, in fact in Big Bear’s class. She used to hear them read and was quite infamous amongst the parents for making slightly judgemental comments in their take home books.

I have noticed that if you smile at her she tends to look the other way.

I feel a little uncomfortable that she is a parent too and that she is going to know lots of things about Little Bear’s background and his behaviour and his learning needs. I have to assume that she is a consummate professional.

I am going to need her to start speaking to me though because I consider there to be a team around Little Bear, consisting at the moment of the teacher and myself & Grizzly, and Mrs. C will soon be an integral part of that. We will need to work closely together and will need to be consistent in our approaches. I am trying to keep an open mind and am hoping that we can achieve the partnership that I’m aiming for.

Little Bear’s teacher and I have agreed to let Mrs C settle in and get to know Little Bear and then for us to have a meeting in maybe the third week. This will help us all get up to speed and hopefully signal the start of a good working relationship.

Unfortunately Mrs C has been tied up in her old contract and has not been able to meet Little Bear during his transition weeks. The school have provided a different TA for the interim. Little Bear has bonded with her well and has been happy to work with her. His teacher and TA have been impressed with what he has been able to achieve with support. He has concentrated well and been co-operative.

There is an obvious risk that the inconsistency of returning to a different TA could throw Little Bear. There is a risk that he may not bond with her as easily and may not be as keen to work with her. I hope this is not the case and it is just my natural tendency to think of all the things that could possibly go wrong talking. I am keeping everything crossed that Mrs C’s firm approach will be ideal for him and that he will work with her quite happily.

My chat with the teacher also revealed that whilst things are going pretty swimmingly in the mornings, the afternoons are a different story. Little Bear does not have support in the afternoons. He seems to be doing ok with accessing the carpet time plenary session but when the children are meant to be doing some independent recording it sounds as though he is doing whatever he fancies. I can see why he would because he cannot do independent writing yet and it sounds as though he is struggling to occupy himself with something constructive and is tending to get into a bit of bother instead. The reduced supervision will be difficult because we know he has a tendency to lash out where verbal negotiation is needed and we also know that the other children have a tendency to purposefully push his buttons. With the best will in the world the teacher cannot see everything at once and it is quite a full on class. I can see why things are going belly-up.

It sounds as though the one thing that will occupy him is the IPad… I really don’t want him to spend every afternoon glued to a screen. Hmm.

Also, it seems as though Little Bear is not being particularly co-operative with things such as tidying up when asked. This is interesting because he generally will tidy things away if I ask him to at home. Ever the opportunist I suspect he is just doing what he can get away with. It is so important that we all handle situations like this in the same way otherwise Little Bear picks up on the inconsistency. When he detects that the boundaries aren’t particularly clear or firm I do think that his anxiety rises and his behaviour deteriorates.

My plan is to let the holidays happen and to send an e-mail ready for the start of term with some thoughts on things that might help. Perhaps it would be helpful to have a bank of activities that would occupy Little Bear when he can’t access the work – things that would provide him with a bit more variety and learning potential than the IPad alone. I’m also wondering about alternative recording options for him such as recordable switches and talking tins, until his writing has developed a bit more. I will need to be clear about how we manage it if Little Bear refuses to tidy up or turn the IPad off when asked.

It could be that afternoons without support are not ok but we’ll have to see how things go.

The conversation made me even more thankful that we got the funding that we did and made me shudder to think what things could have been like if Little Bear was trying to manage whole days without tailored support.

I need to forget about it all for now though: school’s out! I have no idea how a whole academic year has gone already. Time really does fly.

When I tucked Little Bear in tonight I told him how proud I am of him and how well he has done at school. I know it hasn’t been plain-sailing but overall I am very happy with how his first year has gone. He’s done brilliantly. Over the summer we can really focus on his speech and keep trucking with the reading and writing. I know school is out but the learning needs to continue. He’s pretty keen these days and we can easily weave lots of learning into the things he chooses to do.

So far I am feeling keen and enthusiastic for my task ahead but I think we should take bets as to how long I will last before I’m tearing my hair out and counting the days until term starts again!

 

 

Living with Speech and Language Difficulties

As I was driving Little Bear home from preschool today we had a very frustrating conversation. It went like this:

Little Bear: I want that one Mum

Me: That what?

LB: That button.

Me: Ok. Which button?

LB: That one (pointing)

Me: I can’t see matey.

LB: That one (pointing).

Me: I’m driving. I can’t see. Which one?

LB: THAT ONE!!!

Me: Try to use a word to tell me

LB: That button.

Me: (Trying a different approach) ok. Is it on the steering wheel?

LB: No.

Me: Is it the radio?

LB: Yes

I switch from CD to radio.

LB: Not that!!

Me: You didn’t mean the radio?

I switch back to CD.

LB: I want that one.

Me: That what?

LB: That button (pointing)

Me: (Trying not to sound annoyed) we’re nearly home. When we stop you can show me.

It was the skip button. He wanted a different track on the CD.

It’s very frustrating because he knows what he means; he just really struggles to find the right words to explain himself. I think in this case he was struggling to understand why I couldn’t just look at where he was pointing (I had sneaked a peak but there are a lot of buttons in a car, all in a very similar place) and why I didn’t just know by the powers of telepathy.

Sometimes, Little Bear does know the word he needs but I still struggle to understand him because his speech is unclear too. The evening before the CD incident, we had experienced one such struggle. My brother and I had picked Little Bear up and he was very excitedly trying to tell us what he had been up to. “I find dasha” he said. “You found a dinosaur?” “no, da sha” “erm, dancer? Dasher?” “DA SHA!”. I’m not sure how many times he repeated it. In the end I had to say that my ears weren’t working properly and then e-mail his keyworker to try to get to the bottom of it.

Treasure! The word was “treasure”. As soon as we had figured it out it was obvious. I couldn’t believe I hadn’t clicked at the time. The trouble is that in the early days, Little Bear had so few words that I knew exactly how each one sounded. Once I had tuned in, I could understand probably 95% of what he said. However, since then, he has had such an exponential growth in his vocabulary that it’s impossible to keep up. His longer sentences and myriad of words mean that his speech sound difficulties have become more apparent. Consequently I can now probably only decipher 80 to 85% of what he tries to say, bless him.

I must clarify that last paragraph though because obviously the improvement in his language is a good thing. Back at the start of life with Little Bear I had a few shock moments when I realised how profound Little Bear’s lack of life experience was and what a huge impact this had had on his language development. At 3 and a half years old, even with a recognised language delay, I still expected him to know basic vocabulary e.g. cow. But he didn’t. We saw a cow and he said “horse”. We saw a horse and he said “horse”. We had to teach him that they were two different animals with different names. We talked about a cow making milk. It was quite a revelation for him. We saw a train and he said “bus”. Every vehicle on the building site was a “digger”. I looked back to when Big Bear was a similar age and could reel off “dumper truck”, “bale fork”, “roller”, “teleporter” and I saw a word mountain towering in front of Little Bear.

The mountain wasn’t just made of nouns but verbs, concept words (big, same, hot etc), connectives, pronouns. And not just words on their own but words waiting expectantly to be ordered into sentences, preferably with some consideration for grammar. It was a big mountain.

Well, Little Bear would have said it was “bik” and he didn’t know “mountain”. In those days, everything was bik. “Bik” could mean “I want A LOT of ketchup” or “I want my water pistol FULL” or “that water is DEEP” or HUGE or MASSIVE or TALL. But Little Bear only had the one word for size or quantity so “bik” it was. “Bik” shows me how Little Bear has scaled that forbidding mountain, how he has clawed his way up it against all odds. “Bik” has gone now, replaced with its correct counterpart “big” and all the words in capitals are now part of Little Bear’s every day vocabulary.

Back when we were still in the foothills of vocabulary mountain, I found it hard to tell whether we were making progress or not. People would say “isn’t his language coming on?” and I would say “is it?!” and feel mildly ridiculous that as a Speech and Language Therapist I wasn’t a bit clearer about this. However, after a while it was patently obvious that we were climbing fairly rapidly upwards. Sometimes I’d leave him for a couple of hours (with grandparents or at preschool) and feel as though he had more language when I came back than I had left him with. The length of his sentences is increasing all the time, he is continuing to grow his vocabulary and I can see signs of change in his speech.

However, the mountain we are scaling is massive and as the CD example shows, there is some way to go yet. Amongst other things, we need to work on auditory memory. Like many children with Speech and Language Difficulties, Little Bear is much quicker to learn through his visual channel than any other way. He has a good sense of direction; he can remember where he has seen items so is good at finding things; he can learn a visual sequence e.g. the I pad code; he can solve visual problems e.g. how to open a lock. In comparison, his auditory skills are much weaker. It’s not really a surprise seeing as though less than a year ago he wasn’t really tuned in to language at all. He wasn’t used to paying attention or listening to the spoken word. Consequently his comprehension of language is also delayed. We have always needed to simplify instructions and be prepared to repeat them again and again to give Little Bear chance to process them. He has made enormous progress with this too but I am becoming aware that his auditory memory is not really providing him with the support it should. Auditory memory is meant to be a kind of holding pen for words that come into your brain from your ears. It should sit the words down on a virtual bench, all in the right order and keep them there for a few seconds until other parts of the brain have had chance to make sense of them. Little Bear’s bench is a bit wonky though, maybe it has a leg or two missing and the words can’t sit on it. They keep falling off before he’s had chance to figure them out and some of the words probably don’t even make it onto the bench at all. Repetition is crucial for him: it maximises the chances of the words getting onto the bench.

I think Little Bear’s difficulties with learning to count could be due to this faulty auditory bench. He has learned a few number names but he just can’t hold them on his bench for long enough or in the correct order to be able to retain the sequence.

Luckily, auditory memory is a bit like a muscle and can get stronger with exercise. This strengthening is hanging above us on the language mountain.

We also need to work on Little Bear’s sound awareness system. He finds longer words a bit tricky and misses syllables out so that “guitar” and “car” end up sounding the same. He needs to begin to understand that words start with different sounds. He needs to learn to make a “l” sound and that sharp and map end with ‘p’, not ‘k’ or ‘t’. He needs to learn that some sounds are noisy and some are quiet. He needs to learn how to say his name so that people can understand it. He needs to learn that “4” is not the answer to “what’s your name?”. That answer goes with “how old are you?”. “How old are you?” is not the same as “how are you?”.

It’s a big mountain.

Most of all, we want him to be able to express all of those thoughts and ideas and wishes that are currently held captive in his brain. We know they are there, clamouring to get out but the exits are currently blocked by inadequate language skills. It is upsetting to see him get frustrated and to try to chat with his peers but often fail at this because they cannot understand him.

We continue to scale the sheer rock faces though – so far there has thankfully been no plateau to wait around on. I cannot help but turn every activity into a language learning opportunity and I’m probably modelling words in my sleep! It’s a big mountain but we will reach the top. One day.

 

 

If you have any concerns about your child’s communication skills, or want to know more about the role of the Speech and Language Therapist, check out my Guide to Speech and Language Therapy on the Adoption Social: http://theadoptionsocial.com/blogless-blogging/speech-and-language-therapy-a-guide/